{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T21:14:48Z","timestamp":1791234888629,"version":"4.1.0"},"reference-count":25,"publisher":"American Academy of Pediatrics (AAP)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2015,2,1]]},"abstract":"<jats:sec>\n                  <jats:title>BACKGROUND AND OBJECTIVE:<\/jats:title>\n                  <jats:p>Parental refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in some communities. Such clusters could pose public health risks and barriers to achieving immunization quality benchmarks. Our aims were to (1) describe geographic clusters of underimmunization and vaccine refusal, (2) compare clusters of underimmunization with different vaccines, and (3) evaluate whether vaccine refusal clusters may pose barriers to achieving high immunization rates.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>METHODS:<\/jats:title>\n                  <jats:p>We analyzed electronic health records among children born between 2000 and 2011 with membership in Kaiser Permanente Northern California. The study population included 154\u2009424 children in 13 counties with continuous membership from birth to 36 months of age. We used spatial scan statistics to identify clusters of underimmunization (having missed 1 or more vaccines by 36 months of age) and vaccine refusal (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>RESULTS:<\/jats:title>\n                  <jats:p>We identified 5 statistically significant clusters of underimmunization among children who turned 36 months old during 2010\u20132012. The underimmunization rate within clusters ranged from 18% to 23%, and the rate outside them was 11%. Children in the most statistically significant cluster had 1.58 (P &amp;lt; .001) times the rate of underimmunization as others. Underimmunization with measles, mumps, rubella vaccine and varicella vaccines clustered in similar geographic areas. Vaccine refusal also clustered, with rates of 5.5% to 13.5% within clusters, compared with 2.6% outside them.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>CONCLUSIONS:<\/jats:title>\n                  <jats:p>Underimmunization and vaccine refusal cluster geographically. Spatial scan statistics may be a useful tool to identify locations with challenges to achieving high immunization rates, which deserve focused intervention.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1542\/peds.2014-2715","type":"journal-article","created":{"date-parts":[[2015,1,20]],"date-time":"2015-01-20T03:52:49Z","timestamp":1421725969000},"page":"280-289","source":"Crossref","is-referenced-by-count":172,"title":["Geographic Clusters in Underimmunization and Vaccine Refusal"],"prefix":"10.1542","volume":"135","author":[{"given":"Tracy A.","family":"Lieu","sequence":"first","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G. Thomas","family":"Ray","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola P.","family":"Klein","sequence":"additional","affiliation":[{"name":"Division of Research, Kaiser Permanente Northern California, Oakland, California;"},{"name":"Vaccine Study Center, Kaiser Permanente, Oakland, California;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cindy","family":"Chung","sequence":"additional","affiliation":[{"name":"Department of Pediatrics, San Rafael Medical Center, Kaiser Permanente Northern California, San Rafael, California; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Kulldorff","sequence":"additional","affiliation":[{"name":"Department of Population Medicine, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"417","published-online":{"date-parts":[[2015,2,1]]},"reference":[{"issue":"5","key":"2021120907005859900_B1","doi-asserted-by":"crossref","first-page":"848","DOI":"10.1542\/peds.2011-0400","article-title":"Alternative vaccination schedule preferences among parents of young children.","volume":"128","author":"Dempsey","year":"2011","journal-title":"Pediatrics"},{"issue":"14","key":"2021120907005859900_B2","doi-asserted-by":"crossref","first-page":"1757","DOI":"10.1001\/jama.296.14.1757","article-title":"Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence.","volume":"296","author":"Omer","year":"2006","journal-title":"JAMA"},{"issue":"1","key":"2021120907005859900_B3","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1001\/jama.282.1.47","article-title":"Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles.","volume":"282","author":"Salmon","year":"1999","journal-title":"JAMA"},{"issue":"24","key":"2021120907005859900_B4","doi-asserted-by":"crossref","first-page":"3145","DOI":"10.1001\/jama.284.24.3145","article-title":"Individual and community risks of measles and pertussis associated with personal exemptions to immunization.","volume":"284","author":"Feikin","year":"2000","journal-title":"JAMA"},{"issue":"5","key":"2021120907005859900_B5","doi-asserted-by":"crossref","first-page":"470","DOI":"10.1001\/archpedi.159.5.470","article-title":"Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study.","volume":"159","author":"Salmon","year":"2005","journal-title":"Arch Pediatr Adolesc Med"},{"issue":"12","key":"2021120907005859900_B6","doi-asserted-by":"crossref","first-page":"1389","DOI":"10.1093\/aje\/kwn263","article-title":"Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis.","volume":"168","author":"Omer","year":"2008","journal-title":"Am J Epidemiol"},{"issue":"6","key":"2021120907005859900_B7","doi-asserted-by":"crossref","first-page":"1446","DOI":"10.1542\/peds.2008-2150","article-title":"Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children.","volume":"123","author":"Glanz","year":"2009","journal-title":"Pediatrics"},{"issue":"1","key":"2021120907005859900_B8","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1001\/archpediatrics.2009.244","article-title":"Parental refusal of varicella vaccination and the associated risk of varicella infection in children.","volume":"164","author":"Glanz","year":"2010","journal-title":"Arch Pediatr Adolesc Med"},{"issue":"5","key":"2021120907005859900_B9","doi-asserted-by":"crossref","first-page":"994","DOI":"10.1016\/j.vaccine.2010.11.085","article-title":"Parental decline of pneumococcal vaccination and risk of pneumococcal related disease in children.","volume":"29","author":"Glanz","year":"2011","journal-title":"Vaccine"},{"issue":"4","key":"2021120907005859900_B10","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1542\/peds.2013-0878","article-title":"Nonmedical vaccine exemptions and pertussis in California, 2010.","volume":"132","author":"Atwell","year":"2013","journal-title":"Pediatrics"},{"key":"2021120907005859900_B11","unstructured":"Kaiser Permanente Northern California Public Affairs\u2014Resource Center. 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